In Australia, many social workers believe that improving the effectiveness of hospital discharge planning and reducing readmission rates are two important issues that are indispensable in the current medical environment. These two interrelated issues reflect the duality of the solution needs to guarantee the effectiveness of successful discharge of hospital patients and address key problem related to the cost of discharge planning. The social work intervention which contributes to effective discharge planning is evidenced by a social workers ability to manage patients continuing care needs at hospitals and in without recurring need for acute or emergent care services. Transitional care models with social workers focus on the coordination and continuity of care for high-risk patients such as the elderly and patients with high utilization conditions such as heart failure. However, regardless of their risk status or their post-discharge environment, all of the hospitalized patients require some form of discharge planning from the first day of their hospitalization. Efficient and effective discharge planning of hospital patients requires the support of multi-disciplinary teams to proactively address patients discharge requirements. At the same time, as a hospital social worker in the , it is necessary to ensure that patients are ready to discharge when they reach the medical goal.
In this article, I identify three systematic reviews.
Two of them target the elderly group. Hickman et.al (2015) focus on to enhance the effectiveness of discharge plans for the elderly by conducting comprehensive early discharge plans with elderly patients. Hickman et.al (2015) believe that treatment based on a clear communication strategy can reduce the re-admission rate of the elderly. Meanwhile, improving the responsibility of hospital social workers in the transition model is an important part of improving the health outcomes of the elderly in discharge planning. There are six studies in this systematic review which reported complex intervention and only two of them included social workers in the multi-disciplinary team. By identifying and evaluating different multi-disciplinary team interventions, it is possible to indicate the role of social workers in multi-disciplinary teams and to optimize the discharge of the elderly in emergency care settings. The results show that both teams with social workers have significant benefits in improving the functional status and independence of in their daily activities. This also reduced the number of re-admission and emergency visits for the first three months. As a result, the findings of this systematic review are related to my chosen question.
Preyde and Brassard (2011) conducted a systematic review which explores how to improve the effectiveness of discharge plan for the elderly by synthesizing the medical, physical, psychological and social risk factors associated with the adverse health outcomes of elderly patients at discharge. Although this report has been published for 8 years, I think it is still very useful in 2019. They believe that the current health care system is making older patients who discharged from emergency care facilities sicker. Therefore, the re-admission of elderly patients is very common. However, the re-admission could be one aspect of the adverse outcomes of social work discharge planners. As a result, social worker interventions, such as early identification of risk factors, may ensure a successful transition from hospital to home to increase the effectiveness of the discharge plan.
The last one target the patients with heart failure. Albert (2016) highlighted how health care providers (such as general medical nurses, social workers, psychologists, dieticians, and cardiac rehabilitation staff) can implement transitional care services for patients with heart failure, including providing patients with effective discharge plans to promote knowledge and participate in self-care. The purpose of Alberts review is to evaluate existing care transition models and identify common themes: maximize the effectiveness of the discharge plans, minimize the number of patients rehospitalization, and improve the quality of patients life with heart failure. When multi-disciplinary providers, especially social workers, act as liaisons and educators during the transition from hospital to family, they help patients with chronic heart failure prepare for discharge and improve the effectiveness of their discharge plans. There are eight common themes of transitional care described in this systematic review related to patients with heart failure. Meanwhile, the second theme is about the multi-professional teamwork, communication, and collaboration. It points out that effective communication between social workers and patients/family is critical to the transition from hospital to home, and patients sometimes have a sense of conflict, worries and anxiety because the attention from the health care team is suddenly removed. As a result, social work intervention is important to effective discharge planning.
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